Blog | Thursday, March 15, 2012

QD: News Every Day--Prediabetes guidelines need common A1c level for cost-effective interventions


Lowering the A1c cutoff for prediabetes leads to less cost-effective preventive interventions, concluded CDC researchers.

Three major medical organizations have three different recommendations for prediabetes: the American Diabetes Association sets is at 6%, the International Expert Committee sets it at 5.7%, and the Expert Committee on the Diagnosis and Classif─▒cation of Diabetes Mellitus sets it at 5.5%.

So, who's right? The Centers for Disease Control and Prevention study looked at the issue from a cost-effectiveness standpoint, and determined that, assuming a conventional $50,000/QALY cost-effectiveness benchmark, the A1c cutoffs of 5.7% and higher were best. (Learn how to handle prediabetes from a clinical standpoint in ACP Internist's article on the subject.)

The CDC researchers created a Markov simulation to examine the cost effectiveness associated with a progressive 0.1% decrease in the A1c cutoff from 6.4% to 5.5% using the data of nondiabetic American adults from the National Health and Nutritional Examination Survey (1999-2006).

The study looked at two different interventions: a high-cost, resource-intensive approach that cost on average almost $1,000 per year, and a low-cost intervention with an annual cost of $300 per year. Researchers measured the cost per each quality-adjusted life year (QALY) at each A1c cutoff for both interventions.

Results appeared in the American Journal of Preventive Medicine.

Cutoffs of 5.7% and above were cost-effective, based on the conventional $50,000/QALY cost-effectiveness benchmark. The optimal cutoff may be lower if the cost of preventive interventions could be lowered without compromising effectiveness.

Lowering the A1c cutoff would increase the health benef─▒ts of the preventive interventions at higher costs. The high-cost approach lowered the A1c cutoff from 6.0% to 5.9% and from 5.9% to 5.8% would result in $27,000 and $34,000 per QALY gained, respectively. Continuing to decrease the cutoff from 5.8% to 5.7%, from 5.7% to 5.6%, and from 5.6% to 5.5% would cost $45,000, $58,000, and $96,000 per QALY gained, respectively.

For the low-cost intervention, the A1c cutoff from 6.0% to 5.9% and from 5.9% to 5.8% would result in $24,000 and $27,000 per QALY gained, respectively. Continuing to lower the cutoff from 5.8% to 5.7%, 5.7% to 5.6%, and 5.6% to 5.5% would cost $34,000, $43,000 and $70,000 per QALY gained, respectively.